Provider Demographics
NPI:1730254616
Name:WELLMAX MEDICAL CENTER INC
Entity type:Organization
Organization Name:WELLMAX MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:NNAMDI
Authorized Official - Last Name:OKAGBUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-385-9850
Mailing Address - Street 1:5736 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-4152
Mailing Address - Country:US
Mailing Address - Phone:773-385-9850
Mailing Address - Fax:773-637-9774
Practice Address - Street 1:5736 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-4152
Practice Address - Country:US
Practice Address - Phone:773-385-9850
Practice Address - Fax:773-637-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG58196Medicare UPIN
IL578570Medicare ID - Type Unspecified